Subcapsular hemorrhage of the liver after laparoscopic cholecystectomy, a case report

(1)

190

Widjaja et al _{Med J Indones}

Subcapsular hemorrhage

of

the

liver

after

laparoscopic

cholecystectomy,

a

case

report

Suwandhi

Widjaja*,

Sumanto

Simont, Aru Witjaksono

Sudoyol

Abstrak

Seorang wanita berusia44 tahun dengan diagnosis kolesistitis kronika denganbatu kandung empedutelnh dilakukan kolesitektomi laparoskopik. Setelah tindal<an, penderita mengeluh nyeri pada perut kanan atas disertai penurunan hemoglobin. Pada pemeril<sacn USG maupun CT-scan terlihat adanya perdarahan subkapsular hati pada lobus kanan dibawah diafragma. Pada laporan knsus

ini

dibahas mengenai etiologi komplikasi yang sangat jarang ini.

Àbstract

A woman of 44 years old with diagnosis of chronic cholecystitis with gall stones had undergone laparoscopic cholecystectomy. After the procedure, she complained of dull pain in the rtght upper abdomen with the declining of hemoglobin level. The USG and CT-scan examination showed hepatic subcapsular hentorrhage on the subphrenic right lobe. The causes of this very unsual complication was discussed

in

this report.

Keywords

:

Iaparoscopic cholecystectomy, liver rupture, complication

Laparoscopic cholecystectomy

was

first

performed in

France

in

1987.''"

This

technique has

gained

remarkably rapid

widespread use

and

acceptance

all

over

the

world, and

become the standard

for

the

treat-ment

of acute

as

well

as

chronic

cholecystitis.

Retrospective comparative studies between

laparo-scopic cholecystectomy and open

cholecystectomy

showed that

laparoscopic cholecystectomy

resulted on

shorter

hospital

stay, more

rapid recovery,

and

mini-mal use o.fpost

operative

analgesiathan open

cholecys-tectomy.-

"

However,

the

were

comparable

with

open

cholecystectomy

in

types

and

number of complications.5 Complications of this

tech-nique

were problems related

to

distention

of the

peritoneal

cavity,

lack

of

depth

perception afforded by

video image

and

problems related to new instruments

used

in

this

techn1qu".6

Th"

most common

complica-tions

of

laparoscopic cholecystectomy were biliary

duct

injury

such

as

stricture or bile

leakage,

vascular

'

Research Laboratory

for

Viral Hepatitis Atma Jaya School of Medicine, Jakarta, Indonesia

f Department of Internal Medicine, Faculty of'Medicine, University of Indonesia, Jakarta, Indonesia

injury

such as hemorrhage

or

arterio-biliary fistula,

infection/abscess, superficial wound infection,

and

conversion

to open

cholecystectomy.

These

complica-tions

occurred

in

approximately

J.l%

to 7Vo

of

the

procedures depend

àn

Ure

""nt"ir.7'8'e

Although

there were several reports

of

unusual

com-plications

of

laparoscopic

cholecystectomy

reported

as

right

paranephric

s,r.r

arterio-biliary

fis-enlc

rupture,

la

ih"r"

was no any

report

concerned

about

the

liver

rupture

as

the complication

of

this

procedure.

In

this report

we

present a

case

with

subcapsular hemorrhage

of

the

liver

as

an

unusual

complication

of

laporoscopic

cholecystectomy.

CASE

RBPORT

(2)

Vol 8, No 3, July - September 1999

liver function

test

such

as serum

albumin

was

4.4 gldl,

globuline

was

2.3gldl,

direct and

indirect bilirubin

were 0.2

mg/dl

and

0.1

mg/dl

respectively, the

trans-aminases

were

l2Ull

for AST

and

l6U/l

for ALT.

The

blood ureum

was 28

mg/dl.

Laparoscopic cholecystectomy was performed on

the

next day,

in

accordance

to

the

standard

procedure,

uneventful

course

of

the

operation

was

notified.

After

the procedure, the

patient

was

complained

of

dull

pain

in

the

right

upper

abdomen.

The physical

ex-amination

showed no

sign

of

acute abdomen or

hipovolemic shock, however, the hemoglobin level

progressively

declined,

from

12.3 gVo to7 .8 g%o.Based

on

those

findings,

intra abdominal

hemorrhage

was suspected and

USG

was

performed immediately.

The

USG

showed multiple

hypoechoic structures

which

ran

rather

horizontally

among

the

fragmented

liver

tissue

within

subcapsular

liver

right lobe

space,

just

beneath

the

diaphragrn. These

findings

were

com-patible

with

the

liverrupture with

large hematoma. The

CT-scan

was

performed

and

confirmed

these

findings

Figurel [arrow].

These

findings

were

different

to the

pre

operative

USG

,

in

which

the

liver

was entirely

normal without

any

lesion

at

all.

Since the patient's

general

condition

was

not

deteriorated and the

hemoglobin

level

was

not

further declining,

the

con-servative treatment

with

blood transfusion was

ap-plied. The patients

showed

uneventful recovery

and

was

discharge

from the hospital on November

24th

1997.

Figure 1. This CT-scan showed a large sub-capsular hematoma (arrow)

on

the subphrenic right lobe of the liver. The liver was torn horizontally rather vertically.

Liver subcapsular

hemonhage l9l

DISCUSSION

The complications

of

are

divided

into

several catagories. The

most common

complications

are those

the lack

of

depth

perception afforded

by video image

and

new

instru-ments

used

in this

technique.

In this group,

the most

complications

are

vascular

or biliary injury,

which

causes

the

such

bleeding, stricture

of biliary

duct or

biliary

leakage.

The other complications

are related

with

the introduction

of

laparoscopic instrument

through the abdominal

wall, which injures

the

major

blood

vessels

or

the

intestines

.

The

problerns

the distention

of

the peritoneal

cavity

are

also

an

important factor

to

convert

the

laparoscopic

ap-proached

to

open cholecystectomy.

This

complica-tions, such as

adhesions

due

to

prior

operation

or

may cause

the

laparo-scopic

cholecystectomy

became

more delicate

and

in-creased

the likelihood

of

convertion

to

open

cholecystectomy.

In

this

group

of

cornplications,

the

carbon

dioxide

pneumoperitoneum

used during

the

can cause adverse

local

and systemic

effects,

such as gas

embolism,

hypercap-nia, acidosis,

and

arrhyth*iur.r)'

ro' r7

However,

subcapsular hemorrhage

of

the

liver

after

laparoscopic-cholecystectomy

so

far

was never

reported in

the

literatures,

thus

this

is

may

be

the

first

report

in thejournal

.

The

exact cause

of liver

rupture

in

this

case

is

not clearly

defined

because

no

laparotomy

was

performed.

In

this

case,

there

is

no

history

of

abdominal operation, but

she had

obviously

chronic recurrent inflamation

of

the

gall

bladder,

which may induce the

adhesion

of

the

liver

to

the

diaphragm

or

the abdominal

wall.

As

shown

on the

CT [figure

1], the

liver

was, torn

horizontally rather vertically.

This finding

supports

the

suggestions

that the rupture may be due

to

the

disruption

of

the

liver

capsule

by

traction on liver

adhesion

to

diaphragm

by

pneumoperitoneum

or

oc-cured during

the

removal

of

the gall bladder.

This

suggestion may be comparable

with

the splenic

rupture

after

laparoscopic

cholecystectomy

and

during

the

explorative abdominal

operation in which the

splenic

capsule

was torn on

its

adhesion

to

surroundings.la

One other

possibility

is

the

hepatic rupture

happened

due to

injury

by the

introduction

of laparoscopic

instru-ment

during

the procedure.

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Hypercarbia

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